Method and apparatus for performing ACL reconstruction

ABSTRACT

A method and apparatus for drilling a bone for receipt of a first and second bundle includes drilling a first tunnel in the bone. A locating member extending along a first axis from the tool may be positioned into the first tunnel. A cutting guide may be moved relative to the locating member to define a lateral offset between the locating member and the cutting guide. The cutting guide may then be located at a desired offset. The second tunnel may then be formed in the bone with a cutting member associated with the cutting guide, the cutting member having a second axis in a defined orientation relative to the first axis.

FIELD

This invention relates generally to a method and apparatus for use inperforming ACL reconstruction, and more particularly, to a method andapparatus for locating an anterior medial bundle and a posterior bundlein a two bundle ACL reconstruction.

BACKGROUND

Many people today are involved in a sport or some other type of physicalactivity. Some of these activities involve a low risk chance of injury,such as walking and swimming, while others involve a high risk chance orinjury, such as football and skiing.

Damaged ligaments, cartilage and tendons in joints are not an uncommonoccurrence, particularly in some of these high risk activities andsports. One of the joints which requires particular skill and presentsparticular difficulties in repairing is the knee joint.

Numerous improvements in repairing damage to knee joints have been madeover the years, and some of the major advances involve the use ofendoscopic techniques and arthroscopic procedures. Arthroscopic surgeryis particularly useful in excising or repairing damaged knee cartilage.

Endoscopic techniques have also been developed for use in repair andreconstruction of damaged anterior cruciate ligaments (ACL) andposterior cruciate ligaments (PCL). When the ACL in particular hasruptured and is non-repairable, it is usually replaced in young adultsand the knee reconstructed through use of grafts (biological orsynthetic).

In one surgical technique a single bundle reconstruction is performed toreplace a torn ACL. In such a technique, a single tibial tunnel isprepared in the tibia and a single complementary femoral tunnel isprepared in the femur. In one example, U.S. Pat. No. 6,254,605 to Howelldiscloses methods and instruments for preparing the tibial and femoraltunnels.

In another surgical technique a dual bundle reconstruction is performedto replace a torn ACL. In a dual bundle technique, a first bundle isimplanted anteromedially on the tibial site. This bundle is referred toas an anterior medial (AM) bundle. A second bundle is implantedposterolaterally on the tibial site. This bundle is referred to as aposterior lateral (PL) bundle.

To accommodate both bundles, an AM tunnel and a PL tunnel are preparedin the femur. Correct placement of the AM and PL tunnels is vital to asuccessful dual bundle ACL reconstruction. Incorrect tunnel placementmay be a cause of failure in an ACL reconstruction. In some cases ofdual bundle reconstruction however, it is difficult to accuratelyposition one tunnel relative to the other tunnel.

SUMMARY

A method for drilling a bone for receipt of a first and second bundleincludes drilling a first tunnel in the bone. A locating memberextending along a first axis from the tool may be positioned into thefirst tunnel. A cutting guide may be moved relative to the locatingmember to define a lateral offset between the locating member and thecutting guide. The cutting guide may then be located at a desiredoffset. The second tunnel may then be formed in the bone with a cuttingmember associated with the cutting guide, the cutting member having asecond axis in a defined orientation relative to the first axis.

In one example, moving the cutting guide includes translating thecutting guide in a direction along its axis. A first perpendiculardistance may be defined from a point on the cutting member to thelocating member, wherein translation of the cutting guide along its axisdefines a second perpendicular distance from the point on the cuttingmember to the locating member and wherein the first and second distancesare distinct. In another example, moving the cutting guide includesmoving the cutting guide in a direction lateral to its axis.

A tool for preparing a second tunnel relative to a first tunnel in boneincludes a first longitudinal member having a locating member extendingtherefrom. The locating member may be adapted to be inserted into thefirst tunnel. A second longitudinal member includes a cutting memberextending from a distal end. The second longitudinal member may bemoveable relative to the first longitudinal member to define a desiredoffset between the cutting member and the locating member.

Further areas of applicability of the present disclosure will becomeapparent from the detailed description provided hereinafter. It shouldbe understood that the detailed description and various examples, whileindicating various embodiments of the invention, are intended forpurposes of illustration only and are not intended to limit the scope ofthe following claims.

BRIEF DESCRIPTION OF THE FIGURES

The present invention will become more fully understood from thedetailed description and the accompanying drawings, wherein:

FIG. 1 is a lateral view of a tibia and femur in phantom shown with anexemplary femoral aimer inserted through a tibial tunnel and a graftpassing pin drilled through the lateral thigh according to an exemplarymethod;

FIG. 2 is an anterior view of the knee illustrated in FIG. 1 shown witha calibrated acorn reamer used to determine the length of the femoraltunnel;

FIG. 3A is a side perspective view of an exemplary tool used to preparea second bone tunnel relative to an already prepared first bone tunnelshown in a first position;

FIG. 3B is a side perspective view of an exemplary tool according toadditional features used to prepare a second bone tunnel relative to analready prepared first bone tunnel shown in a first position;

FIG. 4 is a side perspective view of the tool of FIG. 3 shown in asecond position;

FIG. 5 is a side perspective view of an exemplary tool according toadditional features used to prepare a second bone tunnel relative to analready prepared first bone tunnel shown in a first position;

FIG. 6 is a side perspective view of the tool of FIG. 5 shown in asecond position;

FIG. 7 is an anterior view of the knee shown with the tool insertedthrough an anterior medial (AM) portal during use according to anexemplary method;

FIG. 8 is an anterior view of the knee shown with AM and posteriorlateral (PL) bundles secured by anchors in respective AM and PL tunnelsaccording to an exemplary method;

FIG. 9A is an anterior view of the knee shown with the tool insertedthrough a tibial tunnel and locating the AM portal according to anexemplary method;

FIG. 9B is an anterior lateral view of the knee with the tool insertedthrough a tibial tunnel during use according to another exemplarymethod; and

FIG. 10 is an anterior view of the knee shown with AM and PL bundlessecured by anchors in respective AM and PL tunnels according to anotherexemplary method.

DETAILED DESCRIPTION OF VARIOUS EMBODIMENTS

The following description of various embodiment(s) is merely exemplaryin nature and is in no way intended to limit the application or uses.Those skilled in the art will appreciate that the following teachingscan be used in a much wider variety of applications than the examplesspecifically mentioned herein. More specifically, while the followingdiscussion is specifically directed toward a tool and method for dualbundle ACL reconstruction, the same may be applied to other surgicalprocedures where locating a second tunnel relative to a first tunnel inbone is desired.

At the outset, an exemplary procedure for preparing a tibial tunnel anda femoral tunnel will be described. For a knee reconstruction involvingan un-repairable or torn ACL, the procedure may begin with a generalanesthesia being administered to the patient. The patient may bepositioned supine on an operating table. A well-padded tourniquet may beplaced proximal on the thigh of the affected leg. An arthroscopic legholder may be placed around the tourniquet. The table may be inclined(e.g. 15 degrees of trendelenburg) and adjusted in height (e.g. waistlevel) according to the desires of the surgeon. The other leg may besecured to the foot of the table. A Mayo stand may be placed over theleg holder and positioned to permit access to the lateral thigh.

The surgical site may be prepped and draped with a sterile seal.Standard arthroscopic draping may be performed covering the Mayo stand.A light cord, camera, motorized instruments, inflow, outflow and suctiontubing may be wrapped and secured to the drape on the Mayo stand. Anirrigation stand may be set up and positioned. The joint of the affectedleg may be examined physically to confirm a rupture of the ACL and todetermine the amount and degree of movement.

The graft harvesting step in the procedure depends on the type of ACLsubstitute that is to be utilized. In one example, the gracilis andsemi-tendinosus tendons are harvested from the patient and used as theACL substitute. In general these may provide grafts which are strongerin the joint than the original ACL and have less postoperativemorbidity. In other examples, patellar tendons, autogenous tendons,frozen and lyophilized tendon allografts, or some of the various knownsynthetic materials may be used as ACL substitute.

After the grafts are harvested, they may be prepared and sized. In oneexample, a surgical assistant may prepare and size the grafts while thesurgeon continues with the rest of the ACL replacement procedure.Sutures may be attached to the ends of the grafts to aid in grasping,manipulating and securing the grafts in place. Incremental sizing tubesmay be used to size the grafts and select the appropriate drills forforming the tunnels. For purposes of discussion, the grafts willhereinafter be referred to as an anterior medial (AM) bundle and aposterior lateral (PL) bundle.

The prepared knee may now be examined by arthroscopic procedures.Standard anterolateral and anteromedial portals may be made for thediagnostic arthroscopy. Proper portal placement is important. In oneexample, the lateral portal may be made at a location one-third thewidth of the patella ligament medial to the lateral margin andpositioned vertically just inferior to the inferior patella tip. Themedial portal may be made vertically, just inferior to the inferiorpatella tip and adjacent to the medial border of the patella ligament.The two portals may be located at the same level.

In one example, wallplasty may be performed to remove a portion of thelateral condylar wall. A tool such as an up-angled, curved and uterinecurette may be used to remove the origin (and stump) of the ACL from theintercondylar roof and the wall of the lateral femoral condyle. Theretained synovial and cruciate remnants may be cleaned and vacuumed witha full-radius resector.

Next, a tibial tunnel 10 (FIG. 1) is prepared. In one example, a Howell™65° Tibial Guide (Howell Guide, not shown) may be used to prepare thetibial tunnel 10. The Howell Guide and a method of using may be found inU.S. Pat. No. 6,254,605, which is incorporated by reference.

With reference now to FIGS. 1 and 2, an exemplary method of preparingthe femoral AM tunnel 12 will be described. Once the tibial tunnel 10has been prepared, a femoral aimer 16 may be inserted through the tibialtunnel 10. In one example, a 12 mm femoral aimer 16 may be used. Thefemur 20 may then be flexed to 90° relative to the tibia 22. The femoralaimer 16 may then be laterally angulated and externally rotated awayfrom the PCL (not shown). A graft passing pin 24 may then be drilledthrough the lateral thigh. The length of the femoral AM tunnel 12 may beequal to the length of the AM graft minus the length of the tibialtunnel 10 and notch (FIG. 2). A calibrated acorn reamer 26 may be usedto measure the length of the tibial tunnel and notch 28. The acornreamer 26 may be inserted over the graft passing pin 24 until it touchesthe intercondylar roof 30. The length of the acorn reamer 26 at thepoint the reamer 26 exits the tibial tunnel 10 is recorded. The acornreamer 26 may then be used to drill the femoral AM tunnel 12 to thecalculated length.

One exemplary method of securing the replacement grafts to therespective AM and PL tunnels includes using interference screws such asa TunneLoc® Interference Screw manufactured by the assignee of thepresent disclosure. Although the following discussion will be directedtoward utilizing interference screws, other methods may be used tosecure the respective AM and PL bundles within the AM and PL tunnels.When preparing the AM and PL tunnels for interference screws, a tunnelnotcher (not shown) may be used to notch the anterior rim of the AM andPL tunnels to facilitate improved contact with the interference screw.

With reference now to FIGS. 3A, 3B, 4 and 7, an exemplary tool 34 forpreparing a PL tunnel 36 (FIG. 7) relative to the AM tunnel 12 will bedescribed. It is appreciated however, that although the followingdiscussion is directed toward locating the PL tunnel 36 relative to theAM tunnel 12, the tool 34 may be used to locate any tunnel relative toan already prepared tunnel. For example, the tool 34 may be used tolocate the AM tunnel 12 relative to an already prepared PL tunnel 36. Inanother example, the tool 34 may be used to locate one bone tunnelrelative another bone tunnel for receipt of a dual bundle (anterolateralbundle and posteromedial bundle) posterior cruciate ligament (PCL)replacement.

The tool 34 generally defines a first and second longitudinal member 40and 42 defining a first and second axis 44 and 46, respectively. Thefirst longitudinal member 40, hereinafter referred to as an aimer,includes a foot or locating member 50 extending outwardly therefrom. Thelocating member 50 defines a locating axis 52. In one example, thelocating axis 52 may define an angle α relative to the first axis 44 ofthe aimer 40. The second longitudinal member 42, hereinafter referred toas a cutting guide, is adapted to slidably translate within acannulation defined in the aimer 40. The cutting guide 42 mayselectively retain a cutting member or drill 56 at a distal end 58. Thedrill 56 defines a cutting axis 60. In another example, the drill 56 maybe integrally formed with the cutting guide 42.

The cutting guide 42 is adapted to be linearly translated within theaimer 40. In the exemplary tool 34, a handle 62 may be provided on aproximal end 64 of the cutting guide 42 and adapted to extend through aslot 64 defined on the aimer 40. As a result, a surgeon may manipulatethe handle 62 along the slot 64 to alter a distance D1 measured betweenthe distal end 58 of the cutting guide 42 and a distal end 70 of theaimer 40. It is appreciated that the handle configuration is merelyexemplary and many other mechanical arrangements may be provided forallowing a surgeon to translate the cutting guide 42 within the aimer40. For example, as shown in FIG. 3B, a threaded rod 62′ may beprovided. The threaded rod 62′ may be rotated and threadably advancedrelative to the aimer 40.

Translation of the cutting guide 42 relative to the aimer 40 allows thesurgeon to select a desired distance or bridge between the drill 56 andthe foot 50. As illustrated in FIG. 3, a first distance B1 is definedtransverse to a centerline (cutting axis 60) of the drill 56 to acenterline (locating axis 52) of the foot 50. Translation of the cuttingguide 42 within the aimer 40 alters the distance D1. As illustrated inFIG. 4, a second distance B2 is defined transverse to the centerline ofthe drill 56 to the centerline of the foot 50. As a result, the surgeonmay drill the PL tunnel at a desired location relative to the AM tunnelfor a given patient. In one example indicia 72 (72′, FIG. 3B) may beprovided on the aimer 40 or the handle 62 (62′, FIG. 3B) that correspondto the bridge measurement B1, B2. It is appreciated that while thebridge between tunnels may be modified for a given patient, the angle αremains constant. It is contemplated that a series of aimers may beprovided each having a distinct angle α. For example, aimers may beprovided for locating a second tunnel (in this exemplary case, the PLtunnel) at angles such as 5, 10, 15, 20, 25 degrees or others relativeto the first tunnel. In another example, the foot 50 may be adjustablesuch that the surgeon may set a desired angle of the foot 50 relative tothe aimer 40. In yet another example, the length of the foot 50 may beadjustable such that the surgeon may extend or retract the foot 50 for agiven application.

With specific reference to FIG. 7, an exemplary method of using the tool34 will be described. At the outset, the tool 34 may be inserted throughan AM portal 76 until the foot locates into the AM tunnel 12. Next, thesurgeon may translate the cutting guide 42 relative to the aimer 40until a desired bridge is defined. In one example, it may be necessaryto hold the foot 50 against the tunnel wall of the AM tunnel 12 toassure the foot 50 is parallel to the AM tunnel 12. In another example,an outer diameter of the foot 50 may be slightly less than an innerdiameter of the AM tunnel 12 to encourage a tolerance fit and parallelalignment. During translation of the cutting guide 42, it may benecessary to partially retract or further insert the foot 50 relative tothe AM tunnel 12. Once the desired bridge is verified, a guide wire 80may then be advanced through the femur 20. The drill 56 is then used toream the PL tunnel 36. While not specifically shown, it is appreciatedthat a conventional driver may be coupled to the drill 56 to providerotational movement of the drill 56.

Turning now to FIG. 8, an exemplary method for securing an AM bundle 84and a PL bundle 86 to the AM tunnel 12 and PL tunnel 36, respectivelywill be described. Interference screws such as TunneLoc® InterferenceScrews 90, 92 and 94 may be driven by conventional methods into tunnels10, 12 and 36 respectively to securely locate the AM bundle 84 and PLbundle 86.

Referring now to FIGS. 9A and 9B, another exemplary method of using thetool 34 will be described. In this method, the tool may be insertedthrough the tibial tunnel 10 until the foot 50 locates within the AMtunnel 12. As shown in FIG. 9B, the aimer 40 may be cocked in the tibialtunnel 10 to assure the foot 50 located properly with the AM tunnel 12.

As illustrated in FIG. 10, according to another exemplary method, a pairof distinct tibial tunnels 10, 100 may be prepared in the tibia 22. As aresult, the AM bundle 84 and the PL bundle 86 may both be located indistinct tibial tunnels. A fourth bone screw 102 may be used to securethe tibial end of the PL bundle 86. The tibial tunnel 100 may beprepared by any suitable method, such as by utilizing a k-wire andcannulated drill.

Referring now to FIGS. 5 and 6, a tool 134 according to additionalfeatures will be described. The tool 134 includes similar features asthe tool 34. As a result, like reference numerals increased by 100 areused for the tool 134. The drill 156 is located in an offsetrelationship with respect to the cutting guide 42. In this way, thecutting axis 160 is offset from the second axis 146. The tool 134includes a rotating dial 162 adapted to rotate the cutting guide 142within the aimer 140. In the exemplary views shown in FIGS. 5 and 6, thedial is positioned at a location corresponding to the smallest availablebridge B3 (FIG. 5) and the largest available bridge B4 (FIG. 6). It isappreciated that many measurements intermediate B3 and B4 are available.Indicia 172 may be provided on the dial 162 corresponding to the bridgemeasurement. Again, the angle α remains constant throughout rotation ofthe dial 162. As with the tool 34, a series of aimers may be providedfor defining various angles. The exemplary cutting guide 142 defines acircular cross section. It is appreciated that a series of bridgemeasurements may be attained throughout 360 degrees of rotation of thecutting guide 142. In another arrangement, a linear slot may be definedat the distal end 158 of the cutting guide 142 in a directionperpendicular to the cutting axis 160. A rotating dial, such as the dial162 or a handle, such as the handle 162 may be utilized to translate thedrill 152 along the linear slot. Other configurations may be used.

Those skilled in the art can now appreciate from the foregoingdescription that the broad teachings of the present invention can beimplemented in a variety of forms. For example, while the precedingdiscussion explains first, forming a passage in the tissue andsubsequently passing the apparatus through the passage, the same may beaccomplished simultaneously. In one example, a hollow piercing membermay carry the apparatus and concurrently form the passage whiledepositing the apparatus through the passage. Therefore, while thisinvention has been described in connection with particular examplesthereof, the true scope of the invention should not be so limited sinceother modifications will become apparent to the skilled practitionerupon a study of the drawings, the specification and the followingclaims.

1. A method for drilling a bone for receipt of a first and secondbundle, the method comprising: drilling a first tunnel in the bone;subsequently to the drilling, positioning a locating member extendingfrom a tool along a first axis into the drilled first tunnel; slidablytranslating a cutting guide associated with a cutting member in adirection along a second axis, while selectively retaining the cuttingmember within a cannulated sleeve, the second axis of the cutting memberbeing in a defined orientation relative to the first axis; moving thecutting member that extends through a bore in the tool relative to thelocating member while the locating member remains positioned in thedrilled first tunnel to select a desired lateral offset between thelocating member and the cutting member; and forming a second tunnel inthe bone with the cutting member.
 2. The method of claim 1 wherein afirst perpendicular distance is defined from a point on the cuttingmember to the locating member, wherein translation of the cutting guidealong its axis defines a second perpendicular distance from the point onthe cutting member to the locating member and wherein the first andsecond distances are distinct.
 3. A method for drilling a bone forreceipt of a first and second bundle, the method comprising: drilling afirst tunnel in the bone; subsequently to the drilling, positioning alocating member extending from a tool alone a first axis into thedrilled first tunnel; moving the cutting member that extends through abore in the tool relative to the locating member in a direction lateralto an axis of the cutting member while the locating member remainspositioned in the drilled first tunnel to select a desired lateraloffset between the locating member and the cutting member; and forming asecond tunnel in the bone with the cutting member, the cutting memberhaving a second axis in a defined orientation relative to the firstaxis.
 4. The method of claim 3 wherein moving the cutting memberincludes: rotating a cutting guide associated with said cutting memberwhile selectively retaining the cutting member within a cannulatedsleeve, wherein the cutting guide defines a guide axis offset from thesecond axis.
 5. The method of claim 4 wherein a first perpendiculardistance is defined from a point on the cutting member to the locatingmember, wherein moving the cutting member in a direction lateral to itsaxis defines a second perpendicular distance from the point on thecutting member to the locating member and wherein the first and seconddistances are distinct.
 6. The method of claim 3, further comprising:passing the first bundle through one of the first and second tunnels;passing the second bundle through the other tunnel; and securing thefirst bundle and the second bundle to the bone.
 7. The method of claim 6wherein the bone comprises a femur.
 8. The method of claim 7 wherein thefirst tunnel comprises one of an anterior medial tunnel and a posteriorlateral tunnel and wherein the second tunnel comprises the other of theanterior medial tunnel and a posterior lateral tunnel.
 9. The method ofclaim 7 wherein positioning a locating member extending from a tool intothe first tunnel further comprises: inserting the tool through ananterior medial portal.
 10. The method of claim 9, further comprisingdrilling a third tunnel in a second bone and wherein positioning thelocating member extending from a tool into the first tunnel compriseslocating the tool through the third tunnel.
 11. The method of claim 10wherein the second bone comprises a tibia and wherein the third tunnelcomprises a tibial tunnel.
 12. A method for drilling a bone for receiptof a first and second bundle, the method comprising: drilling a firsttunnel in a femur at a first entry point; positioning a locating memberextending from a tool along a first axis through the first entry pointand into the first tunnel; slidably translating a cutting guide thatextends through a bore in the tool relative to the locating member in adirection alone an axis of the cutting guide while the locating memberremains positioned in the first tunnel while selectively retaining acutting member associated with the cutting guide within a cannulatedsleeve to define at least two lateral offsets between the locatingmember and the cutting guide; locating the cutting guide at a desiredoffset from the at least two lateral offsets; and forming a secondtunnel at a second entry point in the femur with the cutting member, thecutting member having a second axis in a defined orientation relative tothe first axis.
 13. The method of claim 12 wherein drilling the firsttunnel and positioning the locating member comprise advancing a drilland the locating member into the femur along a common direction.
 14. Amethod for drilling a bone for receipt of a first and second bundle, themethod comprising: drilling a first tunnel in a femur at a first entrypoint; positioning a locating member extending from a tool alone a firstaxis through the first entry point and into the first tunnel; threadablytranslating a cutting guide that extends through a bore in the toolrelative to the locating member in a direction alone an axis of thecutting guide while the locating member remains positioned in the firsttunnel while selectively retaining a cutting member associated with thecutting guide within a cannulated sleeve to define at least two lateraloffsets between the locating member and the cutting guide; locating thecutting guide at a desired offset from the at least two lateral offsets;and forming a second tunnel at a second entry point in the femur withthe cutting member, the cutting member having a second axis in a definedorientation relative to the first axis.
 15. A method for drilling a bonefor receipt of a first and a second bundle, the method comprising:drilling a first tunnel into a femur by advancing a drill along a firstdirection; removing the drill from the first tunnel; inserting a toolthrough an anterior medial portal; positioning a locating memberextending from the tool into the first tunnel alone the first direction;slidably translating a cutting guide that extends through a bore in thetool relative to the locating member in a direction along an axis of thecutting guide while selectively retaining a cutting member within acannulated sleeve to select a desired lateral offset between thelocating member and the cutting guide; and drilling a second tunnel intothe femur with the cutting member extending from said cutting guide. 16.A method for drilling a bone for receipt of a first and a second bundle,the method comprising: drilling a first tunnel into a femur by advancinga drill alone a first direction; removing the drill from the firsttunnel; inserting a tool through an anterior medial portal; positioninga locating member extending from the tool into the first tunnel alongthe first direction; rotating a cutting guide while selectivelyretaining a cutting member within a cannulated sleeve, a cutting guidethat extends through a bore in the tool relative to the locating memberto select a desired lateral offset between the locating member and thecutting guide; and drilling a second tunnel into the femur with thecutting member extending from said cutting guide, the cutting memberhaving a second axis, wherein the cutting guide defines a guide axisoffset from the second axis.
 17. The method of claim 16 wherein thefirst direction is the superior lateral direction.